Inspection on 22/06/06 for Tower House

This inspection was carried out on 22nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tower House 28/07/08

Tower House 28/08/07

Tower House 18/11/05

Tower House 04/04/05

Tower House 10/11/04

Tower House 19/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Tower House 10 Tower Road Willesden London NW10 2HP Lead Inspector Judith Brindle Key Unannounced Inspection 22nd June 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tower House Address 10 Tower Road Willesden London NW10 2HP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8933 7203 020 8930 3681 Mrs Mary Mundy Mrs Mary Mundy Care Home 7 Category(ies) of Old age, not falling within any other category registration, with number (7) of places Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registration is increased to 7 older people requiring personal care. You may only accommodate service users in the bedrooms on the first floor when they have been subject to an assessment by a competent person representing the service user and nominated by the placing agency. In the case of a service user who is self funding, the assessment must be undertaken by a competent person who is independent of the home, such as an Occupational Therapist, CPN or Care Manager. This assessment must clearly state that the service user is able to ascend and descend the stairs to the ground floor without the assistance of staff. A copy of this assessment must be retained in the home and be available for inspection. Any such assessments held at the home must be subject to regular external review in accordance with the changing needs, abilities or condition of the service user. 18th November 2005 Date of last inspection Brief Description of the Service: Tower House is a care home providing personal care for 7 elderly residents and at the time of the inspection there were no vacancies. The home is situated in a quiet residential area close to the varied amenities of Willesden Green, and to transport facilities, which include bus services, and the local underground stations of Dollis Hill and Willesden Green. The proprietor of the home is also the registered manager. The home consists of two houses, which have been converted into one property. There is an open plan lounge and dining area on the ground floor with access from both houses. The first floor areas are still separate and each has its own staircase. There are two bedrooms on the ground floor and five bedrooms on the first floor areas. There is a garden at the front and at the rear of the property. There is off street parking space available for 2 cars. Parking in the street outside the home is restricted to permit holders (and their visitors) or pay and display parking. There is level access, via a portable ramp, to the front of the house. Information about the service is recorded within the statement of purpose and the service user guide documentation, which is accessible in the care home. Information about the range of fees can be obtained from the provider/registered manager. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout during a day in June 2006. The inspector was pleased to meet, and speak with all of the residents, and the staff. There were not any vacancies at the time of this inspection. The purpose of the inspection was to spend time with the residents to gain their views of the service, assess key standards, and to follow up and assess as to whether requirements and the recommendations from the previous inspection had been met. The inspection included a tour of the premises, and inspection of documentation, which included resident’s care plans, staff personnel records, medication storage and administration systems, meals, and inspection of a variety of other records. The inspector spent part of the inspection talking with all the residents, and observing interaction between residents and staff. The registered manager was present during the inspection. Staff kindly provided all the information, and documentation requested by the inspector during the inspection. The inspector thanks all the residents and staff who kindly participated in the inspection process. Key National Minimum Standards were assessed during the inspection. What the service does well: What has improved since the last inspection? Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 6 Some maintenance and redecoration work has taken place and there is more planned. The majority of the previous requirements and recommendations have been met. Staff training including NVQ care training has continued to be developed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (6 is not applicable) Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents have their needs assessed prior to moving into the care home to ensure that the care home is suitable for meeting their needs. It needs to be evident that residents and relatives/significant others are involved in this process of assessment. EVIDENCE: The registered manager confirmed that she carries out a pre admission assessment of the needs of prospective residents prior to their admission to the care home. The care plans inspected included evidence of assessment of the residents health, social and welfare needs. There needs to be evidence of the residents (if able) and relatives/significant other involvement in this assessment process. This documentation was not always dated. There was some assessment information and a placement agreement from the funding Local Authority recorded in two of the care plans inspected. The registered manager reported that a newly admitted resident had visited the care home several times prior to her admission. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7,8,9,and 10 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s health social and personal care needs are set out in an individual care plan, but there needs to be development in regard to staff guidance to meet assessed needs of the resident. Medication is stored and administered to residents safely. Arrangements are in place to ensure that the residents are respected and their right to privacy upheld. EVIDENCE: All the residents had a recorded plan of care. Three care plans were inspected. These all included assessment information, which included identified individual health, social care, mobility and behaviour needs. There was recorded staff guidance to meet most of these needs, but this guidance needs to be further developed to ensure that all resident’s assessed needs are being met by the staff. These include meeting communication needs, some resident’s behaviour needs and when residents need assistance with feeding. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 10 The care plans inspected recorded evidence of having been reviewed. A newly admitted resident to the care home had recently had an eight week review. Records confirmed that there is a monthly review and six monthly review of the resident’s progress in regard to meeting their aims and goals. The issue of there being evidence of resident’s being supported in participating in every review of their care plan was discussed with the manager. There needs to be evidence of recorded involvement by the residents and significant others/relatives in the care plans and in its review. Resident’s progress notes were not recorded daily. There needs to be a record of the resident’s progress during each shift including night shifts. The care plans included risk assessment in regard to prevention of falls, and pressure sores, also manual handling assessments. Residents spoke of the staff being caring, and of being very satisfied with the service provided. Records confirmed that resident’s health needs are met. Appointments with the GP, dentist, optician, chiropodist, were documented. Resident’s weight is monitored. A resident attended a hospital health appointment during the unannounced inspection. Residents have access to their own care plans. The manager reported that there were no resident’s who had pressure sores, and that pressure relieving equipment when needed is accessible to residents. The registered manager reported that if residents need specialist assessment ie occupational therapy assessment or physiotherapy assessment they are referred via the GP. The care home has a medication policy/procedure. This medication policy/procedure needs to be further developed to include the action that needs to be taken in the event of an error taking place during medication administration, and in regard to PRN medication (medication to be given when necessary) staff guidance. Any allergies or allergies not known needs to be recorded on the medication administration record. The signatures of staff that administer medication should be recorded. Medication is stored securely, and was judged to have been administered safely during the inspection. The registered manager spoke of assessing/training staff to administer medication, and that staff also receive medication training from an external trainer. This assessment/training documentation was available for inspection. Medication administration records were fully recorded. Resident’s privacy was observed to be respected. Residents spoke of staff being understanding of their needs. A resident kindly confirmed that they wear their own clothes. Residents have access to a telephone. A resident spoke of receiving phone calls from family members. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12,13, 14 and 15 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to enable residents to participate in activities of their choice, and to maintain contact with family/significant others, as they wish. There needs to be further development in regard to the recording of activities participated in by residents. Meals are varied and wholesome, and meet cultural needs. EVIDENCE: The care plans inspected included a ‘social’ assessment, which included preferred activities and hobbies. A care plan inspected confirmed that activities were recorded as a need and staff guidance to meet that need is recorded. A weekly activity chart was displayed. Residents kindly spoke of the activities that they enjoyed which included going to the local shops, the pub, and spending time in the garden. One resident spoke of their participation in gardening. Records confirmed that some residents attended church services; participate in bingo and karaoke sessions, ‘sing a long’ sessions, and go to a local pub. Most of the residents attended a day resource centre during the inspection. The registered manager reported that this was a weekly activity. From speaking to residents and staff it was evident that varied activities did take place, but the recording of activities should be improved. There should be Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 12 recorded evidence that residents have the opportunity to exercise and to participate in exercise sessions if they so wish. The manager reported that visiting hours are flexible and that visitors are encouraged to telephone prior to visiting the home late evening/night. Records confirmed that there are frequent visitors to the home. Visits to residents by relatives/friends were recorded. Resident’s bedrooms confirmed that residents have the opportunity to bring personal possessions into the care home. Residents were offered choices during the inspection. Records are stored securely. The care home has a menu. All the residents had breakfast during the inspection, and the residents who stayed home had lunch. Residents were offered choice during breakfast, and spoke of enjoying the meal. The residents were observed to freely access their own particular foods from the fridge in the dining room area. Fruit was accessible in the sitting room. The manager spoke of discussing with the residents what meals they wanted to eat on a daily basis. Residents who kindly spoke with the inspector were positive about the meals provided, and confirmed that cultural needs were being met. Staff were aware of the particular cultural needs of residents in regard particular dietary needs and preferences. One resident spoke of preparing his own snacks at anytime. Food eaten is recorded and these records indicated that varied and wholesome meals are provided. Residents were offered frequent drinks during the inspection. There is a water dispenser, which is accessible to residents in the sitting room of the care home. A variety soft drinks and fresh, frozen and dried foods were stored. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 and 18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that complaints are dealt with promptly and effectively, and that residents are protected from abuse. There needs to be review of the ‘in house’ protection of vulnerable adults procedure. EVIDENCE: The care home has a complaints procedure, which is documented in the statement of purpose and the service user guide. The complaints procedure is also displayed in the care home. There have been no recorded complaints in the care home since January 2005. It is recommended that the registered manager examine ways of supporting residents to communicate ‘any concerns’ about the service and those these are recorded, and appropriate action taken. The Commission for Social Care Inspection received notification of an anonymous complaint in February 2006 which was investigated via the inspection process, resulting in some requirements. The care home has a protection of vulnerable adults policy/procedure, and the Local Authority guidance. The ‘in house’ policy needs to be amended to ensure that it is clearly recorded that the Local Authority social services be informed prior to any investigation by the home. Abuse awareness should be included in the staff induction programme. The manager reported that staff including her had completed protection of vulnerable adults training. It is recommended that the manager looks into accessing protection of vulnerable adults training that is provided by the Local Authority. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 14 The care home has a whistle blowing procedure/policy. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19, 23 and 26 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The location and layout of the care home is suited for its stated purpose, and is well maintained, and very clean. EVIDENCE: The home is located in a residential road close to the amenities and public transport facilities of Willesden Green. The house is in keeping with other houses in the locality. The home, including the enclosed garden is generally well maintained. Residents spoke of enjoying spending time in the garden in the warm weather. Garden furniture of quality was evident. Residents spoke of being happy with their bedrooms. These were observed to be personalised, light and airy. A tour of the premises took place. A knob to a drawer of a small chest of drawers in a resident’s room needs to be repaired. Several areas in the care home including bathrooms and ensuite bathroom facilities need decorating. The manager spoke of plans to decorate several rooms in the home. There were decorators/builders present during the inspection. A fire extinguisher on Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 16 the landing of the care home needs to be secured to the wall. The electrical lighting fixture in a bathroom has come away slightly from the ceiling and needs repair. The light switch cord of this bathroom should be cleaned and/or replaced. It is recommended that pictures be placed on doors to assist residents in identifying rooms such as bathrooms and bedrooms. This was discussed with the manager. Thermometers to monitor the temperature of the environment were located throughout the care home. The laundry facility is located away from food preparation areas presently located in the house next door. The manager spoke of using the local laundry facility for most of the laundry such as bed sheets. Records informed the inspector that staff had completed infection control training. Two bathrooms did not have paper towels for drying hands. These need to be accessible at all times. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 27,28,29, and 30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that staffing numbers and skill mix meet the needs of the residents. There needs to be an accessible recorded recruitment and selection procedure and required records need to be in place to ensure that residents are protected and safe. Staff receive appropriate training to ensure that they have the skills and competency to meet the needs of residents. EVIDENCE: The staff rota was available for inspection. The rota should record a ‘key’ to indicate the hours that each shift consists of i.e. the manager reported that a ‘long day’ was from 8am to 20.00hrs, but these hours were not evident on the staff rota. Records and the manager confirmed that there were three care staff on duty during the day and two staff on duty at night. The manager works several varied shifts a week. There were additional staff on duty during the morning of the inspection to ensure that the residents had two care staff to accompany them to the day resource centre, and to enable a resident to attend a hospital appointment. Staff were observed to provide care and support to residents in a respectful and sensitive manner. Residents spoke of staff being helpful and caring. The manager reported that she had advertised to recruit for a senior care staff member Liquid eraser must not be used on the rota. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 18 The registered manager reported that two staff were in the process of completing NVQ level 2 care courses, and that another member of staff had completed the course. A senior member of staff was in the process of completing an NVQ level 4 management course, and another was completing a ‘leadership’ course. The registered manager could not access a recruitment and selection policy/procedure during the inspection. Five staff personnel files were inspected. These included most of the required information and documentation, including references, job description and application form. There were two files, which contained enhanced Criminal Record Bureau checks, but these were from the staff member’s previous employment agency. The registered manager informed the inspector that she had applied for these checks. There needs to be evidence of a POVA first check (protection of vulnerable adults check). One staff file contained one recorded reference. The registered person needs to ensure that she receives at least two written references prior to employing any staff. Staff spoke of having received appropriate training. Records confirmed that staff had received health and safety training, infection control training, fire safety, manual handling training and prevention of abuse training, and first aid training. Staff having completed or being in the process of completing NVQ training courses receive statutory training as part of their course. The manager reported that there were plans for all staff to complete basic first aid training. The manager confirmed that all staff receive induction training. This induction training should include abuse awareness training (see Standard 18), reporting and recording procedures, privacy and confidentiality, accident reporting and on-call procedures, and any other issues relevant to their role and responsibilities. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 31,33,35 and 38 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The resident’s benefit from an experienced and competent management approach to the care home. Arrangements need to be in place to ensure that the quality of the service provided by the care home is monitored and improved as necessary to meet the aims and objectives of the home. Resident’s financial interests are safeguarded, and the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The registered manager/provider has managed the care home for four years. She has completed an NVQ level 4 management course. She is a registered nurse. She spoke of her plans to complete an MSc in Nursing, and of having recently completed a ‘mentoring’ course. The staff who spoke with the Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 20 inspector and records inspected confirmed that there are clear lines of accountability within the home. The residents spoke positively of the manager. The home has a quality assurance policy/procedure. There was evidence that care plans and other documentation including policies were reviewed. The registered manager reported that a questionnaire is sent six monthly to relatives and significant others. The registered person needs to establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided in the care home. There needs to be evidence that residents have been consulted in regard to their views of the service. The registered person shall supply the Commission for Social Care Inspection with an annual development plan in respect of any review carried out by her. The manager reported that she did not manage resident’s finances and that relatives or significant others or the residents themselves managed their financial affairs. A resident spoke of managing his own finances. The home has a displayed an up to date employers liability insurance certificate. The required health and safety poster was displayed. Required fire drills and checks are carried out. The care home has an up to date fire risk assessment. The London Fire Service carried out an inspection earlier this year and reported that they were satisfied with the fire systems in place. Fridge and freezer temperatures are recorded. These recordings need to be reviewed, as it appears that staff are recording the fridge temperature as the freezer temperature and vice versa. Staff need to be aware of the safe range of temperatures for fridges and freezers. Maintenance checks of the environment are completed monthly. Up to date electrical portable appliance service checks are recorded. There needs to be evidence that an electrical installation required check has been carried out. The required gas safety check had been last completed in 06/06/05. The registered manager reported that this check was planned. The registered person needs to supply the Commission with evidence that this electrical installation check and the gas safety check has been carried out. The registered manager spoke of plans to develop safe working practices risk assessments. This needs to be actioned by the registered person. There have been no accidents recorded in the care home since 05/11/05. The residents call bell system was in working order when tested during the inspection. Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1)(c) Requirement There needs to be evidence of the residents (if able) and relatives/significant others involvement in the initial and ongoing assessment process of resident’s needs. • The staff guidance to meet all residents assessed needs must be further developed and recorded in the individual care plan documentation. • There needs to be evidence of recorded involvement by the residents and significant others/relatives in their care plans and in the reviews. There needs to be a record of the resident’s progress during each shift including night shifts. • The medication policy/procedure needs to be further developed to include the action that needs to be taken in the event of an error taking place during DS0000035842.V298573.R01.S.doc Timescale for action 01/09/06 2 OP7 12,13 15 01/10/06 3 4 OP7 OP9 12,13,17 13(2) 01/09/06 01/10/06 Tower House Version 5.2 Page 23 4 OP18 12,13(6) 5 OP19 23 6 7 8 9 OP26 OP27 OP29 OP29 23 17 19 13(6) 19 10 OP29 19.1 medication administration. • and in regard to PRN a (medication to be given when necessary) staff guidance. • Any allergies or allergies not known needs to be recorded on the resident’s medication administration record, and care plan. The ‘in house’ protection of vulnerable adults policy needs to be amended to ensure that it is clearly recorded that the Local Authority social services be informed prior to any investigation carried out by the home. • Several areas in the care home including bathrooms and ensuite bathroom facilities need decorating. • A fire extinguisher on the landing of the care home needs to be secured to the wall. • A knob to a drawer of a small chest of drawers in a resident’s bedroom needs to be repaired. Paper towels need to be accessible in bathrooms etc for hand drying Liquid eraser must not be used on the rota. The care home needs to have an accessible recruitment and selection policy/procedure. There needs to be evidence of a POVA first check (protection of vulnerable adults check), if awaiting for an enhanced Criminal Records Bureau check. That each permanent member of staff has a CRB that is undertaken by Tower House, as the employer. Previous timescale 01/05/06 DS0000035842.V298573.R01.S.doc 01/09/06 01/09/06 01/09/06 01/09/06 01/09/06 01/08/06 01/09/06 Tower House Version 5.2 Page 24 11 OP29 19.1 12 OP33 24(1)(2) (3) 13 OP38 13(4) 23 14 OP38 23 15 OP38 12,13,18 not met. That each staff file contains 2 written references. Previous timescale 01/03/06 not met. • The registered person needs to establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided in the care home, and supply the Commission with an annual development plan in respect of any review carried out by her. • There needs to be evidence that residents have been consulted in regard to their views of the service. • Fridge and freezer temperatures recordings need to be reviewed. • Staff need to be aware of the safe range of temperatures for fridges and freezers. The registered person needs to supply the Commission with evidence that: • the electrical installation check has been carried out, • and that the gas safety check has been carried out. The registered person needs to develop recorded safe working practices risk assessments. 01/09/06 01/11/06 01/09/06 01/09/06 01/11/06 Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP3 OP9 OP12 Good Practice Recommendations Assessment documentation should be always dated. The signatures of staff that administer medication should be recorded. • The recording of activities should be improved. • There should be recorded evidence that residents have the opportunity to exercise and to participate in exercise sessions if they so wish. It is recommended that the registered manager examines ways of supporting residents to communicate ‘any concerns’ about the service and that these be recorded • It is recommended that the manager looks into accessing protection of vulnerable adults training that is provided by the Local Authority. • Abuse awareness should be included in the staff induction programme. • The light switch cord of this bathroom should be cleaned and/or replaced. • It is recommended that the rooms such as bathrooms and bedrooms be identified by pictures. The rota should record a key in regard to the hours that the shifts consist of The induction training should include abuse awareness training (see Standard 18), reporting and recording procedures, privacy and confidentiality, accident reporting and on-call procedures, and any other issues relevant to their role and responsibilities. 4 5 OP16 OP18 6 OP19 7 8 OP27 OP30 Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tower House DS0000035842.V298573.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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